Booking form | Mother Birth

Thank you for honouring your placenta.

This form can be used when you have alredy confirmed my availability and you are ready to pay for your service.

If you have not confirmed availability yet, please contact me using the form at the bottom of the page first.

Placenta Booking Form

First name

Last name

Phone

Email

Choose your inclusions. Choose between paying your entire fee now or the 30% non-refundable deposit to hold your spot.

Placenta encapsulation - Raw. FULL PAYMENT.A$290

Placenta encapsulation - Raw. DEPOSIT ONLY.A$87

Placenta encapsulation - TCM inspired. FULL PAYMENT.A$320

Placenta encapsulation - TCM inspired. DEPOSIT ONLY. A$96

Placenta water colour print (with encapsulation). FULL PAYMENT.A$100

Placenta water colour print (with encapsulation) DEPOSIT ONLYA$30

Framed umbilical cord keepsake (with encapsulation). FULL PAYMENT.A$60

Framed umbilical cord keepsake (with encapsulation) DEPOSIT ONLY.A$18

Placenta tincture (with encapsulation). FULL PAYMENT.A$90

Placenta tincture (with encapsulation) DEPOSIT ONLY.A$27

Placenta body balm (with encapsulation)A$35

Placenta water colour art (on an already excising print)A$100

Placenta water colour print (without encapsulation)A$180

Pick up and drop off (20 km surround of Townsville City)A$30

Intended place of birth

Intended place of drop off (if requiring drop off)

Estimated due date / Guess date

Day

Month

Year

Name and phone number of support person

Are you able to provide current* blood work upon request? *Current, tests run during this pregnancy.

Are you able to provide current* test results for HIV, AIDS, Chlamydia and/or Hepatitis upon request? *Current, tests run during this pregnancy.

Have you tested positive for any previously mentioned diseases or other pathogens/sexually transmitted diseases*? If so, please specify.

Are you experiencing any variations or complications during your current pregnancy? Eg. pre-eclampsia, gestational diabetes, intrauterine growth restriction etc, or are you smoking? If yes, please note below. Only required if placenta is to be consumed.

Do you consent to photos of your placenta and/or prints to be shared anonymously online?

Yes

No

Other

Do you have any allergies? If yes, please note below.

Do you understand that this is a service, and you will not be given a product but have to provide the placenta for me to complete this service?

Yes

No

Do you understand that you are responsible of keeping your placenta cold until picked up or delivered?

Yes

No

Do you understand that 30% of your total cost is your deposit, and is not refundable?

Yes

No

The entire fee must be paid by 37 weeks gestation, and your placenta will not be handled until the entire fee is paid.

I agree to these terms

I do not wish to proceed.

Contact for availability, or to book

0478 185 165

To see previous placenta honorings, please visit my Instagram or Facebook page